RecPlex Scholarship Program Application Form

Note:

This application MUST be completed and submitted by the parent/legal guardian of a program participant age 17 and younger, or program participant age 18 and older. Applicants should complete all required fields within the online application and submit the form for consideration. Once an application is received, RecPlex staff will review the information and follow up on the specific documentation required to complete the application.

Processing applications can take two to three weeks. RecPlex will continue to award scholarships as funds allow. Please complete each section entirely to avoid processing delays.

Eligibility Requirements:

The participant/applicant must provide written documentation supporting their hardship to qualify for a scholarship. Scholarships cover instructional programs, aquatic classes, enrichment classes and youth athletics.

Scholarship funds are not available to Village employees and their family members.

Duplicate submissions for the same program in the same calendar year are ineligible for approval. Submissions for a different program in the same calendar year are eligible for approval.

RecPlex will continue to award scholarships as funds allow. If you have questions, please contact Sandy Wiedmeyer at swiedmeyer@pleasantprairiewi.gov

This Scholarship Program is NOT available for RecPlex Memberships at this time.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name*

First NameLast Name

Phone*

Please enter a valid phone number.

Email*

example@example.com

Have you previously applied?*

YesNo

Are you currently employed?*

YesNo

Employer Name

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation

Is your spouse/partner employed?*

YesNo

Spouse/Partner Employer

Spouse/Partner Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Spouse/Partner Occupation

Monthly Household Net Income (Include all sources of income)*

Choose One Option Below*

Most Recent Federal Income Tax Return (showing low-income status)Participation in Free Lunch ProgramFood Stamp EligibilityFinancial Hardship

Please submit a financial hardship description along with one of the three options above.*

Program Participant 1 Name*

First NameLast Name

Participant 1 Age*

Participant 1 Grade*

Please be as detailed as possible to the program you are requesting assistance*

Participant 2 Name

First NameLast Name

Participant 2 Age

Participant 2 Grade

Please be as detailed as possible to the program you are requesting assistance

How did you hear about the Scholarship Program?*

Signature*

Date*

Date

RecPlex Scholarship Application Form

Contact Information

Employment

RecPlex will need verification of the following. A staff member will follow-up for documentation after application submission.

Program Information for Financial Assistance

Applicant's Signature (18 years or older)